Antibiotic Prescribing, Guideline Adherence May Vary by Care Setting


An assessment from the Cleveland Clinic shows prescribing concordant to guidelines can exceed 60% in certain facilities.

A Cleveland Clinic cohort assessment of their antibiotic prescribing, concordant to guideline recommendations, show the health system is aligned with nationally available rates of outpatient prescribing in an era of notably excessive oral antibiotic prescribing in the US.

The new data, presented at the Making A Difference in Infectious Disease (MAD-ID) 2021 Annual Meeting this week, showed variable rates of antibiotic prescribing among outpatient clinics, as well as blueprint for large health systems to assess their efforts toward stewardship.

Investigators, led by Alex Taylor, PharmD, sought to compare the antibiotic prescribing habits among 5 different ambulatory care departments at the Cleveland Clinic Health System:

  • Emergency department
  • Express care
  • Express care online
  • Pediatrics
  • Primary care

They observed the pattern of prescribing at these facilities from June 2019 – May 2020, for the following conditions:

  • Cystitis
  • Otitis media
  • Pharyngitis
  • Sinusitis
  • Upper respiratory tract infections (URTIs)

As they noted, up to 50% of all antibiotic prescriptions in the US—of which there were nearly 250 million in 2018—are considered unnecessary by treatment practice and guidelines, according to the Centers for Disease Control and Prevention (CDC).

“Regardless of the recognized importance of ambulatory antibiotic stewardship, access to timely, detailed antibiotic use data has limited efforts,” they wrote.

Taylor and colleagues assessed outpatient antibiotic stewardship through the health system’s database, which includes ICD-10 diagnosis codes for the indicated diseases.

Observed baseline characteristics in the retrospective study included age, gender, penicillin allergy history, Group A Streptococcus (GAS) test results, and single or multiple infectious disease diagnoses at the time of encounter.

Characteristics observed in encounters included patient visit type, site location, provider type, order set utilization, prescribed antibiotics, and concordance with antibiotic guidelines. Investigators conducted descriptive statistics and univariate analyses to compare all 5 cohorts. A 1:1 pairwise comparison was conducted comparing the best cohort against the remaining 4, in the event of observed statistically significant difference.

Investigators observed 261,947 encounters at ambulatory care sites for the treatment of cystitis (n = 30,932), otitis media (n = 22,094), pharyngitis (n = 59,964), sinusitis (n = 53,693), or URTIs (n = 95,264). The patient population was 63% female, with a median age of 34.2 years (IQR, 12.8–56.3). Penicillin allergies and GAS testing were observed in 17% and 18% of all patients, respectively.

Antibiotics were prescribed in nearly half (44%) of all observed encounters, most predominantly in the Express care (49%) and Express care online (53%) facilities (P <.001).

Antibiotic prescribing concordant with guidelines were observed in 65% of encounters, most predominantly in Express care online (84%) and Pediatric (75%) facilities (P <.001).

“Observed rates of antibiotic and guideline concordant antibiotic prescribing were similar to national published rates of antibiotic prescribing in the outpatient setting,” investigators concluded. “The variability in antibiotic prescribing demonstrates opportunities for targeted outpatient stewardship efforts.”

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